=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316246986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE HARBOUR LIVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2011
-----------------------------------------------------
Last Update Date | 03/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3784 FREMONT DR
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-6660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-474-4472
-----------------------------------------------------
Fax | 770-972-1791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3784 FREMONT DR
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-6660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-474-4472
-----------------------------------------------------
Fax | 770-972-1791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. TALIS BURRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-474-4472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 031013099
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 031013099
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------